If form is not working or you have any questions please call (02) 9046 8408

Select who will be the client (select BOTH a & b if parent & child having sessions or BOTH have Mental Health Plans)*

a) Child Client

b) Adult Client

c) 2 Child Clients

Child's Name*

FirstLast

Child's Date of Birth (eg 11/10/2002)*

1st Child's Name*

FirstLast

1st Child's Date of Birth (eg 11/10/2002)*

1st Child's Date of Birth (eg 11/10/2002)*

2nd Child's Name*

FirstLast

2nd Child's Date of Birth (eg 11/10/2002)*

Adult client NAME*

FirstLast

Adult's Date of Birth (eg 11/10/1978)*

Your Email Address*

Mobile Number (for sms appointment reminders)*

How did you hear about Amanda Elliott Psychology?*

Google/Searching Online

A friend

GP

Paediatrician

Occupational Therapist

Speech Therapist

School staff (Guidance Officer/teacher)

How will you claim a REBATE*

Medicare - a Mental Health Plan will be used

Private Health Insurance

No Rebate - but a paid invoice to be emailed

NDIS funding

Private Health Insurer Name (Eg BUPA, Medibank or HCF)*

Private Health Membership Number*

ADULT Medicare Card number*

NUMBER in front of ADULT's name on the MEDICARE CARD (eg 1, 3)*

CHILD Medicare Card Number*

NUMBER in front of CHILD's name on the MEDICARE CARD (eg 1, 3)*

1st CHILD's Medicare Card Number*

NUMBER in front of 1st CHILD's name on the MEDICARE CARD (eg, 1, 3)*

Does the 2nd CHILD have the same Medicare card number as the 1st CHILD (i.e. the Medicare number you entered above)*

Yes - It is the same as I entered Above

No - They have a different Medicare number

2nd CHILD's Medicare Card Number*

NUMBER in front of 2nd CHILD's name on the MEDICARE CARD (eg, 1, 3)*

Address REGISTERED WITH Medicare*

AddressSuburbPostcode

Is your BANK ACCOUNT registered with Medicare*

YES - Medicare Rebates will be paid into this account

NO/UNSURE - You will need to contact Medicare to register your bank account either Before or After your first session

NAME OF PARENT Claiming the Medicare Rebate (ie who the Rebate is paid to)*

DATE OF BIRTH of PARENT Claiming the Medicare Rebate*

Does the PARENT CLAIMING REBATE have the same Medicare card number as the child/children (i.e. the Medicare number you entered above)*

Yes - It is the same as I entered Above

No - I have a different Medicare number

Different Medicare Card Number of PARENT CLAIMING REBATE*

NUMBER in front of PARENTS's NAME on the MEDICARE CARD (eg 1, 3)

If you have a Mental Health Treatment Plan (MHP) or referral from your GP or Psychiatrist already, we need you to enter some information from it below to be able to process your rebate faster. Or leave the following boxes blank if you to not have a copy of your MHP or referral with you now. IMPORTANT - when you get the MHP you need to take a picture of your MHP or referral on your phone/scan it and email it to us (taking it to the session will result in rebates taking longer to process)

What is the date of your 1st or next booked session (Eg 02/09 or 04 Oct)

Disclaimer and Consent

All our services and your use of this website are subject to our Privacy Policy and the Terms and Conditions listed below:

1. Amanda Elliott is your "treating psychologist" responsible for your care, you are "the client" (yourself or the child or adolescent you are organising services for), and Changes Psychology is the admin and billing service "provider" that is only responsible for processing clients' bookings, billing and client administration only on behalf of your treating psychologist. Aberfoyle Psychology is the location of the practice rooms used for sessions. By signing this agreement you are agreeing to the provision of services under this arrangement

2.Privacy - Amanda Elliott Psychology takes your privacy seriously. We work like a virtual clinic office, collecting and managing personal and medical information digitally from you and your psychologist, which naturally includes sensitive health information. We collect, use and (where appropriate) store this information, which includes health information, in order to facilitate appointments with psychologists; manage payment, medicare and insurance claims; and manage records regarding your appointments. We manage your information in accordance with our ethical guidelines. For more about privacy, and who to contact if you have questions or complaints regarding privacy, see our Privacy Policy.

3. Your treating psychologist will not provide information, reports or documentation for medico-legal or family court related purposes unless required to by law, under a subpoena or by a court order.

4. Parenting plans - if there is a parenting plan in place we require the parent or person engaging the treatment to meet the all requirements of the plan, it is not our responsibility to share information with other parents or stakeholders.

5. Information sharing - If you would like the psychologist to share and collect information about your child with your ex-partner/teacher/OT etc, we need written consent from you to approve this sharing of information with each individual. However if you intend to claim rebates from Medicare or another organisation is paying for the services, then your psychologist must provide summary reports to the referring GP, Paediatrician, Psychiatrist or external agencies regarding your treatment progress in order to be able to give you Medicare rebates and meet the legal obligations of this funding. By agreeing to these terms and conditions you agree to this information sharing policy.

6. Confirming your first appointment booking - To confirm the first session booking, all new clients consent to completing the Claiming, Consent and $50 booking deposit (that will be $50 credit towards your first session) via the online form and payment portal link that will be emailed to you within 48 hours of receiving the information email- your card details will be processed for the $50 deposit only and your card details stored securely encrypted within the NAB (National Australia Bank) Transact system for all future session fee payments, so no-one will view your full card details.

7. Cancellation Policy - If you cancel your first session the psychologist will retain the $50 booking deposit that can be used against future session bookings. If you wish to cancel or re-schedule an appointment without cost, we require at least 48 hours notice. Session bookings cancelled within 12-48 hours of the appointment time will attract a $120 cancellation fee (50% of the full fee). If you cancel with less than 12 hours notice, you will be charged the full amount for the cancelled session.

8. The session fee for all of your Treating psychologist's services is $240 per 50 minute session, and this amount will be deducted in full after every session from the stored credit/debit card you provide to us. Payment needs to be received before Medicare rebates or Private Health Invoices are processed. All session fee and cancellation fee payments will be taken via our online payment system NAB Transact within 24 hours of your session being completed. All payments will show up on your credit or debit card statement/online banking with the payment reference 'Changes Psychology Northgate' (NOT Amanda Elliott Psychology

To agree to the Terms & Conditions above, and Privacy Policy, SIGN IN THIS BOX with your finger (on mobile device) or use your mouse*